Healthcare and Medicine Reference
In-Depth Information
Complications following pleural aspiration
Box 9.2 Causes of transudative pleural effusions
Complications include the following.
Left ventricular failure
Liver cirrhosis
Pneumothorax —Intercostal drain insertion may be necessary.
Hypoalbuminaemia
Bleeding —Apply direct pressure.
Peritoneal dialysis
Hypothyroidism
Nephrotic syndrome
Spleen or liver puncture —Request an ultrasound of the chest with
marking of the site for aspiration if fl uid is diffi cult to detect.
Constrictive pericarditis
Meig's syndrome (associated with ovarian tumours)
Malignant seeding along track —If mesothelioma is suspected then
mark the site of aspiration indelibly to guide radiotherapy.
Box 9.3 Causes of exudative pleural effusions
Malignancy
Pleural effusions - clinical assessment
Mesothelioma
A pleural effusion can be defi ned as fl uid in the pleural space.
There are many causes of pleural effusions and they are commonly
classifi ed into transudates and exudates. In patients with a normal
serum protein, a transudate is where the pleural fl uid protein is less
than 30 g/L and an exudate is where the pleural fl uid protein level
is greater than 30 g/L. In borderline cases (pleural fl uid protein
25-35 g/L) or where the patient has an abnormal serum protein,
Light's criteria can be applied. The effusion is an exudate if it meets
any of the following criteria:
pleural fl uid protein : serum protein ratio >0.5
Parapneumonic effusions
Empyema
Pulmonary infarction
Rheumatoid arthritis
Autoimmune diseases
Pancreatitis
Chylothorax
Benign asbestos effusion
Drugs
pleural fl uid LDH : serum LDH ratio >0.6
pleural fl uid LDH more than two-thirds the upper limit of
Aspiration of a pneumothorax
normal serum LDH.
A pneumothorax is defi ned as air in the pleural space. A primary
pneumothorax can occur in healthy people with no pre-existing
lung disease, whereas a secondary pneumothorax may occur in
a patient with underlying lung disease (e.g. chronic obstructive
pulmonary disease).
Management
Management of a patient with a pleural effusion should involve the
following.
History, examination and chest X-ray.
Treat heart failure if present with diuretics.
Indications for aspiration
Primary pneumothorax if patient is symptomatic and/or a rim of
Perform pleural aspiration which may be diagnostic or therapeu-
tic depending on the volume of fl uid drained.
Determine whether the pleural effusion is an exudate or a
air greater than 2 cm is seen on the CXR.
Secondary pneumothorax if patient is minimally breathless, aged
transudate.
Further investigations may be necessary if the diagnosis remains
unclear (e.g. CT of the thorax, pleural biopsy).
under 50 years of age and with a small pneumothorax (<2 cm
on CXR).
Step-by-step guide: performing an aspiration
of a pneumothorax
Give a full explanation to the patient in simple terms and ensure
Transudative pleural effusions
These are caused by either increased hydrostatic pressure or
decreased osmotic pressure in the microvascular circulation.
Treatment is directed at the underlying cause. Causes of transuda-
tive plural effusions can be found in Box 9.2.
1
they agree to the procedure.
Set up your trolley. You will need the equipment detailed in
2
Box 9.1 plus a three-way tap and a large cannula. You will not
require the specimen containers.
Firstly confi rm the side of the pneumothorax by clinical exami-
Exudative pleural effusions
These are caused by an increase in capillary permeability and
impaired pleural fl uid reabsorption. Treatment is directed at the
underlying cause as well as measures to improve symptoms and
remove pleural fl uid such as pleural aspiration or intercostal drain
insertion. Causes of exudative pleural effusions can be found in
Box 9.3.
3
nation and review of the CXR.
A strict aseptic technique should be used.
4
5
The patient should be sat upright supported by pillows. The site
of aspiration should be in the second intercostal space in the
midclavicular line.
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